Category: Spotlight Edition 5: Youth Edition

The latest edition of Spotlight, produced by TAC and SECTION27, is a special edition, edited by a young woman activist and SECTION27 researcher, Thuthukile Mbatha. It focusses on the state of implementation of sexual and reproductive health rights (SRHR) in South Africa. The edition illustrates that whether it be on access to termination of pregnancy, access to health services or the continued decriminalisation of sex work South Africa is failing badly in its duty to realise SRHR. In this article Mark Heywood and Thuthu Mbatha, attempt to ask, and suggest some answers to, the hard and painful questions arising from the articles in Spotlight. Why are we failing to advance – or even defend – rights issues that are central to our very being? Part 1 provided some analysis on the state of affairs. Part 2 published here makes an attempt to share some insights into what can be done. Mark and Thuthu do not pretend to have all the answers or to be authorities on the subject. This is an attempt to get an important conversation going and Spotlight will aim to publish a numbers of other opinion pieces on the subject.

Part 1 in the series ends with the statement that we have become complicit with a horrendous status quo. We kick off Part 2 with some suggestions about how we can change this.

SRHR require a struggle for power and equality.

Let’s be clear: SRHR cannot be achieved without confronting issues of power – particularly who has power and who doesn’t. Although they seem to be loved by Northern donors SRHR are not ‘soft’ or easy rights. Their realisation would have an immediate bearing on improved health and HIV prevention, but that recognition doesn’t seem to be enough to persuade policy makers to act on them. In reality their implementation requires a challenge to men’s power in the world not only in the home, but particularly in politics and economy.

SRHR may exist in law and policy in many countries, they may be acknowledged in the SDGs, but they don’t get budgets. This is because men dominate parliaments and men don’t take SRHR seriously. SRHR require a revolution.

SRHRs are relevant to all people of all ages, but they are especially important for and to young people. Young people are in the phase of their lives where they are discovering the potential joy of sex and learning about their sexuality. South Africa’s Constitutional Court has recognised that:

“the majority of South African adolescents between the ages of 12 and 16 years are engaging in a variety of sexual behaviours as they begin to explore their sexuality.” Sexual experiences during adolescence, in the context of some form of intimate relationship, are “[n]ot only . . . developmentally significant, they are also developmentally normative.”

Yet despite this the law continues to deny young people access to sexual and reproductive health care services. Only last year did the Department of Basic Education (DBE) finalise a policy on HIV in schools.[1] Only in 2018 has the DBE published a very poorly written draft policy on Pregnancy in schools.[2] Given that 59% of our population is under 30, and 17% are between the age of 15 and 24 of which nearly five million are women, this amounts to the denial of access to health care services to which they are legally entitled to a lot of people.[3]

Most women give birth before they reach the age of 30.[4] So, that’s when we most need recognition of these rights. Yet the world is mostly run by older people. For example, the average age of MPs in our National Assembly is over 50. SRHR therefore also force us to reflect upon the age and interests of the people who makes decisions and how these decisions reflect their priorities and preoccupations. They call for youth to mobilise and become much more involved in politics.

SRHR require us to recognise that experiencing sexual pleasure and freedom without risk is a right.

It is wrong to communicate and advocate for sexual and reproductive health rights as just/mainly about negative obligations and preventing harm. Young people especially pay little heed to SRHR because they are often spoken about as if they are primarily about minimising risks rather than enhancing pleasure, freedom and equality.

Another weakness in campaigns for SRHR is that they are often most spoken about by middle class people who have them; and, or, they are driven by a donor agenda that makes assumptions about the people who need them and takes little account of their real lives and needs. The people who most need SRHR are poor and marginalised. They experience multiple rights violations. There is a fight for survival, every day. They do not have the luxury to fight only for their SRHR.

Activists must start to assert SRHR as positive rights. They have been recognised in law because they are necessary to enhance human joys and freedom. They are vital for the achievement of freedom and equality, freedom particularly for women and girls, and for marginalised people and populations.

SRHR require us to join the dots between sex and struggles for equality and social justice in education and health.

Relevant SRHR at schools include access to well taught and informed life orientation programmes, that inform young people about sex, sexuality, sexual health and their rights. They should also include access to condoms, access to Pre-exposure Prophylaxis (PrEP) and voluntary medical circumcision for boys. But these rights cannot be achieved without being joined to struggles for social justice and equality in the provision of education.

Today South Africa’s basic education system fails poor learners without discrimination. Of every 100 learners who enter the education system at grade 0, fewer than 5 complete school with a qualification that admits them to University education.[5] However, girls and young women bear the main burden of this failure.[6] The denial of a quality education, the denial of knowledge and information, the denial of a safe learning environment, reduces a young woman’s power and autonomy.

Having been failed by the education system, a young woman falls into a society that further marginalises her in higher education and the economy. This disempowerment may affect a women’s ability to stand up for her SRHR. It predisposes poor women and girls towards older men (‘sugar daddies’) and in some cases sex-work, it leaves many women dependent on men and subject to domestic violence. The question for activists then is how we can integrate campaigns for SRHR into struggles for quality basic education.

A similar situation exists in relation to access to health care services. Because sex and reproduction can be affected by and impact on our health, and because the people most in need of these rights are poor, many SRHR depend upon a functional, accessible and quality public health system, a health system that has sufficient doctors and nurses, appropriate medicines and a budget to meet needs. A health system designed more with the users in mind as well as with the rights of health workers, for example the simple matter of clinic hours. Many patients complain that operating hours are solely determined by what suits healthcare workers with no consideration for what is best for those who need the services.

The issue of the right to abortion (termination of pregnancy) is an example of all that is wrong. It is also an example of the overlapping of SRHR with health and basic education rights. South Africa has a high rate of teenage pregnancy, starting at a shockingly young age.[7] The right to abortion doesn’t only exist on paper; it exists in law, and the law is explicit that a girl can seek a termination without involving her parents from the age of 12. Yet less than one in five (20%) of health facilities offer abortion. According to Marie Stopes International, 245,211 unsafe abortions were carried out in South Africa in 2010 alone.[8] SRHR would be advanced if there was a properly trained cadre of community health workers, able to play a role in community based health education on issues including sexual and reproductive health.

So the question facing human rights activists again is how SRHR can be fought for not as stand-alone rights, but as an integral part of primary health care and as an essential part of a National Health Insurance scheme? How can activists research and then educate politicians and policy makers about the personal and social cost of not respecting these rights? How can we gather the evidence to show that a sufficient and dedicated budget for SRHR would be cost-saving to the health system as well as advancing women’s rights to dignity and equality?

This is why SRHR advocacy needs well researched activism, not just slogans – however justified the slogans are. Unfortunately SRH rights are still battle-grounds and battle grounds require a battle plan.

What is to be done?

In South Africa activists have a huge advantage over our comrades in many other countries because of the legal power given to us by the Constitution and because of the entrenchment of SRHR in the Constitution, law and policy. However, no rights are ever capable of enacting themselves. They require campaigns and activism.

Before and immediately after the advent of democracy in 1994 a number of organisations fought valiantly for SRHR, initially the Women’s Health Project, Reproductive Rights Alliance and the National Coalition for Gay and Lesbian Equality. More recently the One in Nine campaign, Soul City, and others have taken forward this struggle. Social justice movements such as TAC, have taken up individual issues that overlap with SRHR, without fighting for these rights as a whole. But at best most civil society organisations have been silent and at worst many, particularly in the trade unions, have been complicit in gender based violence. Today we need to learn from and follow the lead of those who have fought in this field, but also cut a path to a much broader and more powerful activist front. SRHRs must no longer be in a silo. As I have tried to show above, they are central to social justice. We all have a responsibility to make SRHR part of our practice.

Below are some tentative suggestions about the types of campaigns that must be launched and sustained.

Make millions of people aware of their rights: The people who most need SRHR are not aware that the law and Constitution views things such as bodily autonomy and reproductive choice as fundamental rights.[9] Even the term SRHR is confusing and foreign – it is ‘NGO-talk’. To change this a massive and accessible communication campaign is needed that reaches young women and other vulnerable communities to make it clear that they are not powerless in the face of violence and to start to suggest local strategies and campaigns to advance these rights. This campaign must have scale. It cannot reach only small circles of communities. It needs to be carried through public and accessible media, like the indigenous language radio stations on the SABC which reach over 30 million people.

But linked to this a campaign is needed to educate society as a whole about SRHR, overcome misunderstandings and to engage those who think they are opposed to SRHR.

Define an agenda for SRHR: short, medium and longer term and demand action. Below are some examples of demands we should make:

In the short term (2018) we should demand:

A costed, budgeted national strategic plan to confront rape culture.

The immediate and extensive provision of PrEP to young women and girls, including through school health programmes;

Immediate implementation of the policy on access to condoms in schools;

Immediate provision of sanitary pads in every school nationally;

Drastically improved accesss to services for abortion.

Communication and mass media strategies that publicise all of the above.

In the medium term (2019-2020) we should demand:

The decriminalisation of sex work;

Implementation of the draft policy on pregnancy in schools;

Access to a wide range of safe contraceptives in the public health sector;

Extensive provision of contraceptives in schools and higher education institutions;

Improved access to screening, testing, diagnosis and treatment of cancers in the reproductive system;

Improved access to SRH services that are suitable for queer folk and health services that recognise the special needs of adolescents, LGBTQIA+ folk, pregnant teenagers and so on.

In the longer term:

Establishment of more shelters for gender based violence survivors;

Improved access to affordable breast, cervical and prostate cancer treatment in the public health sector;

Get civil society to join the dots and connect its own struggles: Civil society organisations’ greatest weakness, and the reason why we don’t often bring about lasting and systematic change, is that we don’t make enough effort to work together. NGOS and social movements have not yet worked out how to focus on ‘their’ particular issues, but at the same time reinforce others campaigns. We have not learnt how to work at the intersections of issues. Despite all the lip-service we pay to issues of gender and women’s equality, they are almost never at the centre of rights practice or advocacy. Gender and SRHR issues are on the margins unless you are an organisation focussing on ‘woman’s rights’ or LGBTQI issues. And, as we have seen most tragically with regards to Equal Education, even the social justice sector is not immune to the plague of sexual harassment and exploitation. This is not unrelated to the fact that most of civil society, whether in the form of churches, trade unions or NGOs, is led by men and therefore – by default – reflects patriarchy and men’s agendas. Even where women lead organisations, they are not ‘allowed’ to reorient the method and focus of these organisations to take into account gender and a woman’s perspective on the approach to struggle and rights.

In the context of SRHR the biggest problem is that identified by Pumla Gqola: we treat each act of violence, whether deliberate or by omission – as if it is an individual aberration. The only weapon in our armoury seems to be outrage. Outrage is a necessary starting point, but it alone doesn’t bring change. We have to fight a system of rape by consistently demanding and campaigning for a system of rights. In the words of Pumla Gqola:

“… we need to rebuild a mass-based feminist movement, a clearer sense of who our allies in this fight really are, to return to women’s spaces as we develop new strategies and ways to speak again in our own name, to push back against the backlash that threatens to swallow us all whole.”

If this challenge is not taken up by civil society immediately, ultimately our other efforts will be unsuccessful.

[4] Of the 969 415 births registered in 2016, 136 996 (13,9%) were born to mothers who were between the ages of 10 and 19 years old. A large number (783 322) of the births registered in 2016 occurred to mothers between the ages of 20 and 39 years; of these, 243 148 (31%) occurred to mothers within the 20−24 years age group. A total of 34 923 (3,6%) of births registered in 2016 were to mothers in the 40−54 years age group. http://www.statssa.gov.za/?p=10524

[9] According to a recent study by the Foundation for Human Rights http://www.fhr.org.za/index.php/latest_news/democracy-challenged-south-africas-largest-attitudinal-survey-constitution/ only 51% of respondents were aware of the Constitution and the Bill of Rights and “as poverty levels increased, so the awareness levels decreased.” Shockingly, but perhaps not surprisingly “In response to the statement that married women are allowed to refuse to have sex with their husbands, a worrying two fifths (41%) of all respondents disagreed with this statement. Again the differences between male (44%) and female (39%) were not that stark.”

The latest edition of Spotlight, produced by TAC and SECTION27, is a special edition, edited by a young woman activist and SECTION27 researcher, Thuthukile Mbatha. It focusses on the state of implementation of sexual and reproductive health rights (SRHR) in South Africa. The edition illustrates that whether it be on access to termination of pregnancy, access to health services or the continued decriminalisation of sex work South Africa is failing badly in its duty to realise SRHR. In a two-part article, Mark Heywood and Thuthu Mbatha, attempt to ask, and suggest some answers to, the hard and painful questions arising from the articles in Spotlight. Why are we failing to advance – or even defend – rights issues that are central to our very being? Part 1, published here provides some analysis on the state of affairs. Part 2 makes an attempt to share some insights into what can be done. Mark and Thuthu do not pretend to have all the answers or to be authorities on the subject. This is an attempt to get an important conversation going and Spotlight will aim to publish a numbers of other opinion pieces on the subject.

Sexual and reproductive health is a state of physical, emotional, mental and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction or infirmity. Therefore a positive approach to sexuality and reproduction should recognise the part played by pleasureable sexual relationships, trust and communication in promoting self-esteem and overall well-being. All individuals have a right to make decisions governing their bodies and to access services that support that right.

Sex and the enjoyment of sex is universal and timeless. At some point in their life almost everybody fondles and touches and makes love. Most people know the language of sex; it is a universal language, it has its own words. Most people have felt sexual desire deep within themselves, they seek their pleasure in another’s pleasure, they relish the anticipation, the foreplay, the gathering of energy and excitement and the quiet that follows the end of a sexual encounter.

Because it is so central to human life and experience sex is celebrated in poetry, in painting, in all forms of literature, in music, in photography. Sex is associated with joy, intimacy and love. It’s a part of being human, one of our most exquisite and meaningful forms of expression. We have written about it, debated it, perfected it, for the whole of human history.

Sex and the abuse of sex is also universal and timeless. Paradoxically, because sex is so central to human experience of joy, it has a flip side. Rape has been central to slavery, colonialism and apartheid. What Pumla Dineo Gqola calls “the culture of rape” is deeply embedded in our society. Forms of sexual behaviour have also been persecuted and discriminated against. People have been marginalised and persecuted in law because of their sex, sexual orientation or sexual preferences. Even today, sex brings persecution and death. Sexual relationships are inextricably tied up with inequality between men and women as well as other genders; they become chained to issues of power, violence and exploitation.

In this context of oppression, inequality and discrimination, sex is turned into its opposite. It becomes about coercion, powerlessness and pain. As with so many other forms of oppression that rob people of autonomy to protect their own bodies, sex becomes linked to risk of sexually transmitted diseases, like HIV, illness, physical harm and death.

Reproduction is inextricably linked to sex. It’s hard – but no longer impossible – to reproduce without having sex. Reproduction is mostly also about joy: the joy of creation, of parenthood, of the union of two people embodied in their offspring. Healthy reproduction needs healthy bodies and minds. Giving birth should be a moment of exquisite joy for a woman – but it can also be a moment of great risk.

This means reproduction too has a dark downside. It too is meshed into inequality and unequal power relations between men and women. Girls and women are forced to get pregnant against their wishes or forced to have children against their wishes through anti-abortion laws. Some women are denied the right to have children, because of disability or stigma. For example, in some parts of the world women have been sterilised because they have HIV.

And then there’s the issue of patriarchy. In every country in the world it is predominantly men, whether as legislators or judges, who prescribe laws that proscribe women’s control over their own bodies or seek to eliminate non-conforming gender differences.

Global recognition of Sex and Rights

Safe and pleasurable sex and safe reproduction are inextricably connected to those foundational rights that most inhere within us – our dignity, our privacy, our autonomy over our bodies and decisions, our equality as men and women, our sexual identity, OUR FREEDOM. It is in recognition of the centrality of sex and reproduction to our human experience that activists fought successfully for sex and reproduction to be recognised and protected as fundamental human rights. These rights exist primarily to recognise, enhance and protect the joy of sex, our individuality, our sexuality and sexual orientation.

Today, sexual and reproductive health rights are recognised in several international Covenants. Although they were not recognised in the Universal Declaration of Human Rights, the foundational document of the United Nations, they are referred to, recognised or developed in subsequent treaties.

According to researchers the 1994 International Conference on Population and Development (ICPD), in particular, “transformed the approach from reproductive control to meet demographic targets to a more comprehensive and positive approach to sexuality and reproduction, free from coercion, discrimination and violence. ICPD forged the link between sexuality and health as human rights, where women’s agency over their own bodies and sexuality are intrinsically linked to their sexual and reproductive health.” Following this, a year later the Beijing Platform for Action “was the first declaration to embody the concept of sexual rights, and expanded the ICPD definition to cover both sexuality and reproduction by upholding the right to exercise control and make decisions concerning one’s sexuality.”[2]

“By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes”

As well as under Goal 5, ‘Gender Equality’, a commitment to:

“Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences.”

Building on this the most recent significant development in international law was the publication in 2016 of General Comment No 22 on the Right to Sexual and Reproductive Health by the UN Committee on Economic Social and Cultural Rights (UNCESCR).[3] This important document spells out states’ duties in relation to SRHR, such as the right to “education on sexuality and reproduction that is comprehensive, non-discriminatory, evidence-based, scientifically accurate and age appropriate.”

The fact that there is now global recognition of SRHR is a victory for activism. It is evidence of the power of activists when organised around a common vision. It is proof of the adaptability of human rights standards as society struggles to evolve beyond conservative and oppressive ideas of sex and sexuality. Yet, in spite of these positive developments, a 2017 survey found that there is reference to sexual and reproductive health rights in the Constitutions of only 27 out of 195 countries.[4] The UNCESCR says that SRHR are “a distant goal for millions of people, especially for women and girls, throughout the world.” In May 2018 the Lancet Commision on Sexual and Reproductive Health Rights confirmed this, finding that:

At a global level … almost 4.3 billion people of reproductive age worldwide will have inadequate sexual and reproductive health services over the course of their lives and that, each year, an estimated 25 million unsafe abortions take place. Each year in developing countries, more than 30 million women do not give birth in a health facility, more than 45 million have inadequate or no antenatal care, and over 200 million women who want to avoid pregnancy are not using modern contraceptive methods. Intimate partner and non intimate partner sexual violence affects around a third of women in their lifetimes, including an estimated 29% of adolescent women aged 15-19 years who have ever had partners.

In the face of this evidence we must admit that the inability of activists to ensure the domestication and implementation of rights that we have won at an international level – rights that seem to exist on paper – is our collective failure. As we shall see, the fight for sexual and reproductive health rights is far from complete. It needs renewed commitment and a better strategy from activists and progressive governments in the world. It requires self-examination and self-criticism from within civil society and deep introspection.[5] It is urgent, perhaps the most urgent issue we face, because it connects to so many other rights violations.

National recognition of sex and rights

In the early 1990s in South Africa a range of organisations from the women’s health movement and the National Coalition for Gay and Lesbian Equality (NCGLE) campaigned successfully to ensure that sexual and reproductive health rights were included in the new Constitution.[6] As a result, the Constitution declares that no one may be discriminated against on grounds including sex, sexual orientation, pregnancy or gender. But our Constitution goes further. It does not just include negative injunctions against discrimination: the Bill of Rights says that “equality includes the full and equal enjoyment of all rights and freedoms”.

Building on this, section 12 of our Constitution recognises that “everyone” has a right “to make decisions concerning reproduction” and to have “security in and control over their own body”. Section 27 says everyone has a right of access to “reproductive health care”.

In the context of adolescent sex and sexuality, in a very important judgment, our Constitutional Court recognised that in relation to their sexuality “children merit special protection through legislation that guards and enforces their rights and liberties.”

It is important for activists to understand that these grand rights create legal obligations, especially on the government. They ought to translate into specific policies, programmes and budgets. They ought to be evident in concrete programmes such as access to condoms in schools for prevention of teenage pregnancy and HIV; as well as access to medical technologies that can protect and enhance people’s sexual and reproductive lives.

Sexual rights and sexual wrongs in South Africa

You would think that given their growing recognition in domestic and international law, that this aspect of human rights has been placed beyond contest. If only. In reality the global crisis around sexual freedom and reproduction has never gone away. It is being exacerbated by the actions and words of ‘leaders’ like USA President Donald Trump. However, we would be mistaken to think that Trump is the problem. He is just a very visible and unapologetic manifestation of it. Across the world there is an undeclared war on sex and gender. The black American writer Ta-Nehisi Coates called the abuse of black women in the USA during slavery “rape on an industrial scale” – sadly rape on an industrial scale, particularly of black women, continues in many other parts of the world.

In South Africa there exists what Pumla Dineo Gqola insists we must call “a culture of rape”, with deep historical roots.[7] She argues that there has been an unceasing war on women’s bodies and autonomy since the start of colonialism. Today, this is reflected in statistics that reveal:

Poor implementation of policy and law have had the effect of pushing back on women’s rights. For example, in 1996 the Choice on Termination of Pregnancy Act was one of the first progressive laws to be passed by our democratic government. Yet 21 years later only a minority of public clinics offer this service – thousands of women a year are still maimed, and many die, as a result of backstreet abortions.[13] Add to this the epidemics of violence against women, girls and hate crimes perpetrated against sex workers, lesbians (so-called “corrective rape”) and other people because of gender identity or sexual orientation. Finally consider the continued marginalisation of girls and women in our education system and economy, despite the fact that the Constitution proclaims us all to be equal.

All of this violence is linked to the systematic denial, by omission and commission, of the sexual and reproductive health rights that are meant to be respected, protected, promoted and fulfilled under our Constitution and other laws.

All of this is violence on people’s bodies and minds. Consequently much of it leads to illness and trauma.

Almost all of this is preventable.

All of it is connected. Yet people pretend that SRHR can be realised separately from other rights.

In reality we are only half way even to political freedom in South Africa. We have men’s political freedom, but not women’s freedom. We have a degree of freedom for materially secure women but almost none for poor black women. Poverty, race and sex are overlapping and reinforcing oppressions. In the words of activist Naledi Chirwa, “black women can’t breathe.” [14]

So what is going wrong?

Centuries of struggles have won the recognition of human rights in policies and some laws. But their implementation is another story altogether. Worryingly, in a world of conservative men and bigots who have captured religions in order to once again enslave women, it’s clear we can’t take the rights we have on paper for granted.

The failure to “respect, protect, promote and fulfil” (the words of the Constitution) SRHR is first and foremost a failure of government. But the leadership of social justice movements and human rights NGOs cannot escape responsibility. Most trade unions, faith based organisations and NGOs do not take SRHR seriously. Our gender-neutral campaigns, our failure to advance women’s leadership in civil society, are a reflection on the prevailing patriarchy. It is not enough if an organisation says it stands for gender equality (most say we do); unless it actively seeks gender equality, women’s leadership and the realisation of SRHR then its default position is reinforcing patriarchal ‘norms’. That is a sad state of affairs.

[5] In an important article analyzing effective (and ineffective) social justice advocacy Barbara Klugman says the following: “In the context of AIDS denialism, much of the media focus was on the conflict between the government and HIV activists, with very little attention to the lived realities of people living with HIV, nor to the high levels of sexual violence, and cultural imperatives to have children, all of which were key determinants in the escalation of HIV. Claims regarding the need to promote sexual and reproductive rights as a key dimension to preventing HIV brought a level of complexity that this call could not contain, or, argued differently, neither AIDS activists nor reproductive rights activists were able to frame these issues in ways that caught the public and media imagination. Hence, a critical opportunity for broadening and deepeningpublic understanding and legal precedent regarding the scope of reproductive rights and women’s rights in particular, was lost. In the process, public and policy recognition of the right to treatment eclipsed the issues underlying the HIV/AIDS epidemic, in particular the lack of mutuality in sexual and reproductive relationships.” Effective social justice advocacy: a theory-of-change framework for assessing progress, Reproductive Health Matters 2011: 19(38): 146 -163.

With around 2 000 new HIV infections every week in young women and girls aged 15 to 24, South Africa is facing an urgent HIV crisis in young women. Given the scale of this crisis, we need to use all the tools at our disposal to help young women stay HIV-free. And yet, uptake of one of the most exciting new tools is happening at a snail’s pace.

Pre-exposure Prophylaxis (PrEP) involves people who are at risk of HIV taking an antiretroviral to avoid becoming HIV-positive. A number of different kinds of PrEP options have been tested, but so far the form of PrEP that has worked best involves taking a daily pill that combines the antiretrovirals tenofovir and emtricitabine. This combination is marketed under various brand names, and when taken as prescribed, it is extremely effective at preventing HIV infection. PrEP in the form of a vaginal ring has also shown some promise, but appears to be less effective than the tenofovir/emtricitabine pill.

So why are we not providing every young woman in South Africa at risk of HIV infection with PrEP? Why, even in 2018, are we talking about providing PrEP to only in the region of ten or twenty thousand young women and girls in the entire country?

One probable reason is that in many of the trials conducted so far, people simply did not take PrEP as regularly and diligently as they should have, i.e. as prescribed. Of course, this difficulty is to be expected – convincing healthy people to take a preventative pill is hard, especially if there might be some minor side effects associated with that pill. Thus there is a worry that pills purchased by the state may go unused, or be used only intermittently.

A second (and related) reason might be that studies and mathematical models suggest that – from a big-picture public health perspective, at least – PrEP is not the game-changer many hoped it would be. Broadly speaking, to roll back the HIV epidemic, prioritising the treatment and retention of treatment of people already living with HIV will have greater impact than a PrEP rollout. From a public health perspective, then, PrEP might have relatively low priority.

A third probable reason is cost. Though a month’s supply of PrEP should cost the state less than R100 per person, there are also the associated costs of counselling, and ongoing care and monitoring.

While the financial and human resource costs of a PrEP rollout would indeed be significant, this should be offset against the economic benefits of preventing HIV infections. Several studies have been done in South Africa to test the cost-effectiveness of rolling out PrEP to young women, and the evidence suggests overwhelmingly that PrEP could be a cost-effective tool to reduce HIV infections among key population groups – especially because it need not be a lifelong drug; it is only taken when one is exposed to a greater risk of contracting HIV.

However, these reasons pay scant regard to individuals and their rights. The statistics clearly tell us that young women are sexually active, and being exposed to the risk of HIV infection – how else would we have 2 000 HIV infections a week?

By dragging its feet with the rollout of PrEP, the state is saying to young women: “This new tool with which you could protect yourselves exists, but we don’t think you should have it. Even if you know you are at high risk of contracting HIV. Even if you have a violent boyfriend who refuses to use a condom. Even then, we will not give you PrEP to help you protect yourself.”

Section 27 of The Bill of Rights in the Constitution of South Africa states that “Everyone has the right to have access to healthcare services, including reproductive health care”. It then goes on to say that the state must take reasonable legislative and other measures, within its available resources, to achieve the progressive realisation of this right.

Every young woman or girl in South Africa at risk of HIV infection has these rights, just like any other individual in the country. Accordingly, the state is obliged to fulfil these rights, as far as is reasonable and within its resources. That PrEP might not be the big game-changer in the HIV epidemic in South Africa does not matter. What matters is that there is a relatively cheap pill that can help young women and girls stay HIV-free, in the midst of a still-raging HIV epidemic.

Saidy Brown shares how she used social media to speak openly about her HIV

Saidy Brown, one of the Y-Plus coordinators who is living positively with HIV

status.

Doctor Google terrified Saidy Brown. For Saidy, when she was diagnosed with HIV at the age of 14, all the online information sounded like a visitation from hell.

“I read that my teeth and my hair would fall out, and that I’d get a hump on my back. I was so scared, I went into denial,” says Saidy (22), who lives in Mafikeng in the North West Province.

She ignored the results of the random HIV-testing day that she attended as a representative for her school. Denial made her keep her status a secret, even as she continued to Google and the search results continued to freak her out. Eventually – about six months later – she told a teacher, who went with her to tell her aunt.

“I hadn’t been intimate with anyone; and that’s when we realised that I must have been born with HIV,” she says.

Saidy’s dad died when she was nine; her mom, a year later. Her two older siblings, who were tested later, were HIV-negative. “I was really angry, and I couldn’t relate to anyone. I resented my aunt and my siblings and my parents,” she says.

All the while she stayed silent, keeping the secret to just her immediate family. It wasn’t until she turned 18, when sores on her chest spread to her face and neck, that she knew she had to act.

“I was still blaming the sores on the heat, and I would buy umbrellas and shades and hide behind those; but I did know something wasn’t right, so I went to the clinic. They had my records from four years earlier, and the counsellor started to talk to me, and told me to stop believing all the stuff I had Googled about antiretrovirals.

“I said I’d only give six months of my life to the drugs. But it turned out I didn’t have any side effects, apart from some dizziness – but that was okay, because I took my tablets at night,” says Saidy, who’s on a fixed drug combination treatment.

Finding that peace and having the support of her family allowed Saidy to disclose her status; and that’s when she decided to take to Facebook. Her long post, pouring her heart out about everything she had been through over four years, was part of what she calls her personal journey.

And people supported her. There was no judgement, and she didn’t lose a single friend after posting her story. In fact, she’s gained more followers on social media.

But Saidy admits it hasn’t all been plain sailing with her relationships. When she was intimate with a partner for the first time, at 17, she used condoms, but she didn’t tell him her HIV status. She remembers being so in love, but being so scared that she was going to infect him.

Two years ago she was rejected by someone she cared for, who told her he couldn’t have a relationship with her because of her HIV-positive status.

“I won’t lie; it really broke me that he rejected me because of my status. But I think it made me stronger; because if that ever happens again, I think I will be able to handle it better,” she says now.

Today, Saidy says, she feels healthy and strong, and she continues her advocacy work around awareness and drug adherence. She’s part of a youth network for people living with HIV called SAY+, and she counsels other young people about testing, disclosing and managing relationships as an HIV-positive person. She’d like to work in communications one day, and practises by contributing to campaigns in which she shares her story with people – so that they don’t feel they have no-one to turn to, as she did when she was 14.

“I believe that disclosing your status means you’re halfway there. And these days, social media can help to connect you to many people. When you disclose, it’s a moment of accepting that things are what they are, and then you can start getting help,” she says.

Even with her courageous attitude, Saidy admits she still has fears about living with HIV. Fears of inadvertently infecting a partner, and fears that if she has a child one day, she may transmit HIV to her baby. Still, she tries to take her own advice at those emotionally low moments.

“I always let myself go with my emotions, whether I’m sad or angry, and then I remember that these feelings pass and things do get better, and things will be okay,” she says.

Love may be blind; but some things, you shouldn’t ignore – like knowing your and your partner’s HIV status.

South Africa is still considered the world epicentre of the HIV epidemic, with more than 7.1 million people living with HIV in 2016 and around 270 000 new infections that same year, according to Statistics South Africa.

However, as more people gain access to support and improved treatment options for their HIV infection, so they come to live full, healthy lives. They’re also inevitably involved in relationships with people who are not infected with HIV. These mixed HIV-status relationships, where one person is HIV-positive and one is HIV-negative, are called serodiscordant or mixed-serostatus relationships.

Serodiscordant relationships have become part of the ‘new normal’ of our range of relationships. They deserve the right kind of medical advice, management and support to ensure that these sexual relationships don’t come with the risk of HIV transmission.

Researchers join the dots between low knowledge of HIV status and increased risk of transmission between partners. In 2014, Wits RHI researcher Catherine Martin found that up to half of the number of HIV-infected people in her sample group were involved with an HIV-negative partner. Despite this, she found that knowledge of status results was low, with 52.6% of women knowing their status, while only 37.5% of men knew their status.

It makes knowing your status the first step to take in any new sexual relationship. Developing open communication and trust with your partner or partners is also essential. Next, clinicians promote a multi-pronged strategy to manage mixed-serostatus relationships. This entails counselling and good medical advice as a foundation.

Clinicians advocate the ‘Treatment as Prevention’ route. This means that regardless of CD4 count, the HIV-positive partner or partners should start ART as soon as possible after diagnosis. A 2011 study called HPTN 052 found this intervention approach to be 96% effective in reducing transmission of the virus, as viral load can be reduced to be undetectable. Subsequent studies have confirmed that if someone has an undetectable viral load, they are not infectious.

Starting ART as early as possible is not just good for preventing onward transmission of the virus; it is also good for the health of people living with HIV. In 2016, the landmark START trial showed that people who started taking ART earlier were less likely to get tuberculosis or various forms of cancer.

Other critical strategies to manage the sexual relationships of serodiscordant couples and multiple-partner sexual relationships include the use of condoms during sex, as well as undergoing medical male circumcision.

Added to this is the emergence in recent years of pre-exposure prophylaxis (PrEP). PrEP involves people who do not have HIV taking a pill to prevent acquiring HIV. Current PrEP consists of taking a daily pill containing two antiretrovirals: tenofovir and emtricitabine.

It’s also a regime that’s regarded as an appropriate treatment intervention for heterosexual serodiscordant couples who want to conceive naturally. Jennifer Power, a research fellow at the Australian Research Centre for Sex, Health and Society at La Trobe University, writing in The Conversation in April 2015, says that PrEP “re-introduces the possibility of ‘safe’ sex without condoms”, and “allows natural conception with minimal risk. Evidence to date supports the safety and efficacy of PrEP for serodiscordant couples trying to conceive, and it’s seen as a sensible choice”.

The World Health Organisation (WHO) recommendations for serodiscordant couples who want to fall pregnant include ART to suppress viral load; the use of PrEP by the non-infected partner; sexual intercourse without condom use when the woman is at peak fertility; screening and treatment of sexually transmitted infections in both partners; and voluntary medical male circumcision.

It is noteworthy that the WHO acknowledges that serodiscordant couples who would like to have children are “often inadequately supported or face significant barriers to accessing existing sexual and reproductive health services”.

This speaks to the need to challenge stigmas and old societal norms among the general public, as well as among healthcare workers. And along with changing attitudes and behavioural practices, there must also be appropriate policies, legislation, funding, proper implementation and oversight.

This means many layers of responsibility and action coming together for better solutions to minimising the HIV risk for more serodiscondant relationships. It also makes loving whoever you choose that little bit easier to do.

Bonolo’s Story

Leonora Mathe, Treatment Action Campaign

Bonolo (not her real name) was born on 22 September 1987 in Cosmo City, in Johannesburg. She became HIV-positive at birth, and started taking ARVs at the age of 10.

“After matriculating from high school, I had my first boyfriend, who I loved so much; sadly, I lost him as soon as I disclosed my status. He blamed me for wanting to infect him. I was very hurt, because being HIV-positive is not a wrong choice I made; I was born with it.

“Actually, it made me lose my confidence and have low self-esteem, in such a way that I doubted I would ever find an intimate partner again who would love me as I am; but things changed when I met my husband of five years.

“We went out for our first and second dates, and as soon as the relationship started getting serious, I told him I was HIV-positive, and asked if he knew about his status. He took a break from the relationship, because he was scared and confused; but after he consulted clinicians and social workers, they taught him more about HIV. We reunited after six months, and we are married now.

“I would love to have children; and although studies have shown that you can have HIV-free children, I always fear that… what if something goes wrong? But my husband assures me that all will be well, and we should consider trying for one soon.”

When Tshepo Ngoato’s doctor and aunt sat him down to tell him he was HIV-positive, he felt as if his world had crashed before his eyes – that he had been dealt a death sentence.

Now, this 26 year-old man is a role model for many young people, and a co-

Tsepo Ngoato, an inspirational young man who is passionate about the rights of young people living with HIV.

founder of the Y+ network, a volunteer group of young people living with HIV (YPLHIV) who have demonstrated a commitment and connection to a constituency of YPLHIV in South Africa. They work to guide parents and healthcare providers on how to address the needs of HIV-positive young people, such as the appropriate age to inform children about their status, and how to support them thereafter. They also offer psychosocial support to HIV-positive youth.

Tshepo is one of thousands of children born with HIV in South Africa. He found out about his HIV status in 2003, after being diagnosed with tuberculosis (TB). His doctor recommended that they do further tests on him, and he tested positive for HIV. He was told to finish his TB treatment first before initiating antiretroviral treatment.

“The media had portrayed HIV as a death sentence – I thought I was going to die soon,” says Tshepo. When he disclosed to his family and friends, some of them did not take the news well, and decided to distance themselves from him. “I lost a lot of friends and family when I came out about my HIV status,” he adds. This rejection was devastating for the teenager.

Tshepo decided at a young age to be open about his HIV status. “My rule is to tell someone I am (romantically) interested in about my status before we even get into a relationship,” he says.

Tshepo has been living with HIV openly for years, and has established a network of young people living with HIV called Y+, represented in all nine provinces. Y+ is currently finalising consultations with YPLHIV in all the provinces to find out the needs of young people living with HIV, because a large number of them find it hard to talk to nurses or their parents. “We have noted that there are a lot of HIV-positive adolescents who have treatment anxiety also, driven by the fact that they do not even know why they are taking this treatment,” says Tshepo.

Other than being the founder of Y+, Tshepo is expanding his horizons in other ways too. “I am currently completing a Bachelor of Business Administration degree through Milpark Business College in Johannesburg. I am an outgoing person. I enjoy doing outdoors stuff, such as hiking and mountain climbing.”

His message to young people is: “You may see that you are beautiful on the outside; but if you haven’t gone for an HIV test yet, you shouldn’t be confident about knowing what’s beautiful on the inside. You can change this by getting tested, and knowing your health status. That would be a wise decision; you should never be scared of something that involves your health.

“To those already living with HIV, your life is the most important thing; you should value it. Being positive is nothing to fear. Never limit yourself and your strength just because you are positive. Your positivity comes with a lot of reactions; do not change who you are, just change your attitude towards living healthily and taking your pills.”

Young HIV activist Shakira Namwanje (24) has been living with HIV since a very young age, and has become an outspoken and energetic voice in her country. “At school, children used to say I was HIV positive because I was thin; that used to get to me, but I didn’t know that what they were saying was true,” says Shakira.

Shakira was raped at the age of eight, and contracted HIV – not understanding what it was.

The rape happened during the school holidays. Shakira’s mom had left Shakira with her uncle, because she had no-one else to look after her while she was at work. “My mother had us at a very young age; both my parents had to work, so they used to send us to different relatives during the holidays, because there was no-one to look after us during the day,” says Shakira.

Shakira enjoyed spending time with her uncle and his wife, who had just given birth to a son. During the holidays, her uncle and his wife had a huge fight, which resulted in the wife moving out of the house and leaving Shakira and the son behind.

Shakira was comfortable staying with her uncle, who was still young, and used to bring them food during lunch and dinner at night. “My uncle used to own a cinema, where people from the community used to pay to watch movies or soccer. A number of his friends used to come to watch television programmes, so I used to call them my uncles as well,” she adds.

One afternoon her uncle had other commitments, and could not bring the food. He asked one of his friends to deliver food to the children. That was the day Shakira was raped; and she remembers it as the day her innocence and peace were ripped away from her.

Her uncle’s friend called Shakira in to the house, under the guise of helping him search for a parcel that her uncle had asked him to take. Shakira followed him into the house, where he raped her. “He told me to go and wash my clothes, which were covered in blood, and to never tell anyone about what had happened, otherwise he would kill me,” she says, with so much sadness and pain in her voice as she relives the experience. The man told her he would kill her should she utter a word to anyone.

When her uncle returned home, he found Shakira ill and feverish. Shakira was taken to hospital for malaria tests, which came back negative. Her condition worsened, and her uncle decided to take her back to her mother. Shakira’s mother also took her to the doctors, who also could not find anything wrong with her. Shakira suffered in silence. “I used to have nightmares every day following the incident,” she adds. She says the words and memory of her rapist haunted her every day.

Three years later, Shakira’s mother arrived at school to tell her that her uncle had died in a car accident. Shakira was sad, as she had loved her uncle. “But when I heard that my uncle was with his friend who raped me, and he had also died, I started laughing uncontrollably. I was sad that my uncle had died, but also relieved that the person who had stripped me of my freedom and happiness was no more,” says Shakira.

Shakira’s older sister told her that it is rude to laugh when someone has died. Shakira then confided in her sister the secret that she had kept for years, and which had led to her health deteriorating. Her sister told her mother, and she was taken to hospital for an HIV test. She was HIV-positive.

“Suddenly I was taking treatment every day, and I did not even know what for,” she says. Her mother did not take it well. “My mother was advised to take me to a children’s counsellor who works with young children living with HIV. For so long she refused, but eventually she introduced me to Madame Ahseah, a counsellor,” Shakira says. Her mother realised that she could not keep this information away from Shakira as she was growing up, and she became more inquisitive about the treatment that she had to take even when she was feeling well.

“After graduating, I decided to disclose my status to more people, with the hope of changing other young girls’ lives,” says Shakira. She used a community radio station as a platform to disclose what had happened to her as a child, and that she had contracted HIV through rape. She then joined the ‘Because I am a girl’ campaign.

This campaign creates awareness about sexual violence, and offers psychosocial support to young girls who have been victims of rape. They visit different schools to talk to both girls and boys, and encourage boys to respect girls and value them as their sisters. The campaign has touched a number of young girls who have had a similar experience to Shakira’s.

The ‘Because I am a girl’ campaign is an international programme that is run in over 51 countries in Africa, Asia and the Americas. It looks at various issues that affect girls by virtue of being born female and being young. The campaign looks at issues of child marriage, teenage pregnancy and sexual violence, among others.

Shakira’s campaign is targeting an area called Kalangala in Uganda, a fishing

Shakira and the Stigmaless Band

town that has been in the news in Uganda because of an increase in rape cases. It is alleged that there could be more unreported rape cases in the area.

“I have been sharing my story with these young girls, and that has encouraged them to open up to me about what they are going through in their homes. I have assisted many young girls with getting counselling and sexual health services, and with opening criminal cases against the perpetrators,” says Shakira.

Shakira has not been in many relationships, because her mother was very protective of her following the incident. “I had a boyfriend in university who left me, and to this day I do not know why,” she says. “I never had a chance to disclose my status to him,” she adds.

For most people, finding out that you are HIV-positive is not an easy thing to accept. This is fuelled by the stigma. “The first person that I disclosed to was my best friend, who has been very supportive, and to date is still my rock.”

Shakira does not let her HIV status prevent her from living an active and positive life. “I enjoy sightseeing and touring, swimming, going out with friends, singing; and reading is my favourite. I am actually writing a book about my life,” she says. She is also part of a band called Stigmaless, a group of young people living with HIV. “We sing about HIV prevention, treatment drug resistance, and so on.”

Her message to other young people living with HIV is: “HIV is in you, but it’s not who you are – you can be whoever and whatever you want to be. Taking it one day at a time.”

Activists blame government for limited access to abortion services in the public sector.

The streets of Hillbrow bustle with morning traffic. Taxis shoot in and out of the wide avenues as the Spotlight team passes through the palisade fencing and glass doors leading to the overcrowded entrance of the Hillbrow Community Health Centre. Patients sit in queues awaiting attention in the reception area and in the casualty ward. There is a din, as traffic noise competes with hundreds of conversations.

The uniformed security guard dispenses directions and acts as a traffic officer, redirecting people to different areas of the clinic in response to questions: where should I go for this ailment, what should I do with this piece of paper? She is a fount of knowledge – of necessity, as there is little signage other than the ‘Reception’ sign at casualty.

When we ask where the area for termination of pregnancy is, she informs us that the facility no longer offers this service. The sister who used to provide the service left some six months ago, and no-one else wishes to provide it.

This is the dominant narrative in many facilities across the country, according to Professor Eddie Mhlanga. Dr Mhlanga, a devout Christian and an obstetrician, is a strong proponent of choice in termination of pregnancy. He was director of the National Health Department’s Maternal, Child and Women’s Health unit from 1995 to 1999. During that time, he spearheaded the development of legislation to legalise abortion.

In his view: though the legislation is in place, in practice, women are being denied the choice to terminate unwanted pregnancies, because the prerogative of choice over women’s bodies is given to health workers. This is an untenable situation.

“Black women have little or no rights over their bodies in this country,” says Dr Mhlanga. “Their autonomy is restricted by patriarchy, in the guise of cultural practices.”

This is a view shared by outspoken sexual and reproductive health activist Dr Tlaleng Mofokeng, who does not pull any punches.

“Patriarchy and misogyny are systematic,” she says. “Power relations are stacked against women; so when they go into facilities, they feel like the healthcare professional is doing them a favour.”

According to a policy brief by Critical Studies in Sexualities and Reproduction, a research programme based at Rhodes University, just over six out of every 10 (63 per cent) young women in Buffalo City Municipality in the Eastern Cape are not aware of their right to obtain a free abortion in the public sector.

“You can’t fight for a right you don’t know you have,” says Dr Mofokeng. “It suits the department not to do a health education drive on abortion.” It seems the department is not interested in upholding the Termination of Pregnancy Act.

“It was reported some five years ago that only 40 per cent of facilities designated for providing this service were operational,” explains Dr Mofokeng. “This means there is a higher risk of women going to clinics in the second trimester, looking for surgical options – where they won’t be helped.”

Every healthcare facility should be able to offer a medical abortion up to 12 weeks, on a woman’s request. But this is not the case; a large number of facilities have insufficient or no trained personnel, and there is no protocol for referring the woman to another facility. In addition, there are often medicine stock-outs, or the drugs required are not listed on the essential drugs list.

According to Dr Mofokeng, the lack of access to abortion services is the result of a lack of care for women on all levels – from the government itself, represented by the Department of Health, to the Ministry, which does not have accurate statistics. They don’t know and can’t quantify the magnitude of the problem; they are disinterested, and disengaged from all the illegal posters advertising medical procedures.

“This is a primary healthcare issue, and it is the Department’s problem to solve,” says Dr Mofokeng.

Approach abortion with compassion

Spotlight attended a termination-of-pregnancy training workshop delivered by venerated sexual and reproductive health rights activist and medical practitioner Professor Eddie Mhlanga. During the workshop, Dr Mhlanga outlined the circumstances under which a woman of any age may obtain a legal abortion in the public sector. He emphasised that a woman does not require consent from anyone to undergo the procedure, but that those under the age of 18 should be counselled to inform their parents or legal guardian.

Circumstances and conditions under which pregnancy may be terminated

Gestation Period

Circumstances and Conditions

By Whom

Requirements

Up to 12 weeks

On the request of a pregnant woman of any age

Registered Nurse
Registered Mid-wife with appropriate training

Informed consent of the pregnant woman

13 to 20 weeks

Continued pregnancy poses a risk of injury to a woman’s physical or mental health
Would affect social or economic circumstances
Severe physical/mental abnormalities in the foetus
Pregnancy is a result of rape or incest

Doctor

Informed consent of the pregnant woman

After 20 weeks

If the pregnancy would:
Endanger the woman’s life
Result in severe malformation of the foetus
Pose a risk of injury to the foetus

Doctor

Informed consent of the pregnant woman;
consult 2 doctors, or a doctor and a midwife

Here are some of the questions we posed to Professor Eddie Mhlanga.

Who are the women seeking abortion?

“The majority of women who seek to terminate pregnancies, according to the health professionals Spotlight interviewed, are teenage girls. They report that sometimes girls as young as 14 years of age come to their facilities seeking abortions because this is their second child, and their families had forgiven them for the first ‘mistake’, but would not tolerate another; while others report having relationships with teachers or married men, and are not able to look after a child.

Sometimes it is a married woman who has ‘stepped out’ on her husband, who is perhaps out of the province. “I had a case where a woman came to me pregnant with her eighth child,” says Dr Mhlanga. “She had asked the doctor who delivered her seventh child to tie her tubes, but he failed to do so. She was a poor woman who survived on the grants provided by the state, and she simply could not afford another child. In this instance, the compassionate thing to do was to provide her an abortion.”

How many healthcare facilities offer termination of pregnancy services?

“In Mpumalanga, there are 23 facilities in the public sector that offer termination of pregnancy services. This is up from only five facilities three years ago. It is because we conduct training sessions for health professionals throughout the province, and even offer this training to other provinces. We trained doctors and nurses from Gauteng not too long ago.

In Gauteng there are 25 facilities, the majority of which offer the service only for women in their first trimester. Second-trimester terminations are only available at:

Chris Hani Baragwanath Academic Hospital

Sebokeng Hospital

Odi District Hospital

Tembisa Hospital

Services have been terminated at Dr George Mukhari Academic Hospital and Hillbrow CHC.”

How many women die as a result of unsafe abortions?

“The Minister of Health has said in a radio advert that a woman dies every eight minutes as a result of unsafe abortions; however, there are no statistics to corroborate this assertion. During my tenure at the National Health Department, we worked on the protocol for confidential inquiry into maternal deaths, which is published every three years. The last report, published in September 2015, looks at 2014 data; which revealed that in all maternal deaths, 57.3% were considered potentially preventable within the health system. However, there is no data specifically on maternal deaths caused by unsafe abortions.”

What do you think about conscientious objection?

“All healthcare professionals have taken an oath to deliver health care to all who live in this country, as stipulated in section 27 of the Constitution. Therefore, they do not have the right to object to offering the service, and the government should not enable this type of intolerance.

Compassion for the pregnant woman’s circumstances should be the primary motivation for any health worker. Currently, there is no provision in the Act for conscientious objection; and so, health workers are using the lack of clarity to deny women their right to health care.

Many health workers do not have a problem completing a botched abortion, irrespective of the cause; but they refuse to perform one at the request of a pregnant woman. This is grossly unjust.”

The ACDP has presented a private member’s bill to amend the Act. What do you think of the provisions they are suggesting?

“They recommend that a woman has an ultrasound. It is not only a coercive strategy to limit women’s ability to choose to terminate a pregnancy, but also impractical. Currently, there is no curriculum for training doctors to perform an ultrasound examination; it is simply not available in the public service. So this would be an additional burden on an already overburdened system.

In addition: in law, a foetus only becomes a life when it takes a breath; and thus, the argument that terminating an unwanted pregnancy is taking a life holds no credence in law.”

Dr Mhlanga is a lifelong advocate for the sexual and reproductive health rights of women, including the decriminalisation of sex work.

Ever heard of using plain yoghurt, or a mixture of Stoney and Lemon Twist, or

Dr Sindisiwe van Zyl

cinnamon and milk? Well, these are some of the ‘remedies’ that have been recommended to help women douche and get their vaginas to be ‘tight and clean’.

Some people might be shocked by this; but these are just some of the extremes that people go to.

Let’s start off by understanding what douching is.

According to WomensHealth.gov, the word ‘douche’ means to wash or soak. Douching is washing or cleaning out the inside of the vagina with water or other fluids. Most women make their own douching concoctions using water, vinegar, baking soda, yoghurt, cinnamon or iodine.

This last is commonly used by gynaecologists after major surgery.

Douching can lead to infection

The vagina is a self-cleaning organ – it doesn’t need anything to be done to assist it in the cleaning process. When you start douching, you strip the vagina of the bacteria that help it to clean. This leads to infections, the most common being bacterial vaginosis.

The symptoms of bacterial vaginosis are a watery/milky vaginal discharge with a very fishy smell. It smells like tinned pilchards; it’s unmistakeable.

The other infections associated with this practice include vaginal thrush and pelvic inflammatory disease. Women who douche regularly may also have difficulty falling pregnant.

Infections linked to douching

Vaginal Thrush

Vaginal thrush is a common infection caused by an overgrowth of Candida albicans yeast. The yeast lives naturally in the bowel, and in small numbers in the vagina. It is mostly harmless, but symptoms can develop if yeast numbers increase. About 75 per cent of women will have vaginal thrush in their lifetime.

Pelvic Inflammatory Disease

Pelvic inflammatory disease (PID) is an infection of the female reproductive organs. It usually occurs when sexually transmitted bacteria spread from your vagina to your uterus, fallopian tubes or ovaries. The Pelvic inflammatory disease often causes no signs or symptoms. As a result, you might not realise you have the condition, and will not get the treatment needed. The condition might only be detected later if you have trouble getting pregnant, or if you develop chronic pelvic pain.

There are a lot of myths regarding vaginal ‘freshness’, and they are passed down from the elders to us. But oh my word, they are not true. Stay away from douching and ‘intimate washes’ – your vagina does not need them. Water will do the trick: yes, the one we get from the tap.

STIs

Moving on, to another important topic: Sexually Transmitted Infections (STIs). (These were previously called Sexually Transmitted Diseases.) There are different categories of STIs. The trick with STIs is that they must be detected early, and treated accordingly; you need to know what those categories are, so that you can seek treatment timeously. Failure to do so increases the risk of HIV infection. This is why we treat them aggressively.

STIs are passed from one person to another through unprotected sex or genital contact.

Common STIs that affect women in South Africa:

Human papillomavirus

Human papillomavirus (HPV) is a viral infection that is passed between people through skin-to-skin contact. There are more than 100 varieties of HPV, 40 of which are passed through sexual contact and can affect your genitals, mouth, or throat.

Genital herpes

Genital herpes is a common infection caused by the herpes simplex virus (HSV), which is the same virus that causes cold sores. There are two types of HSV: type 1 and 2. Type 1 causes cold sores on the lip. Type 2 causes genital lesions. Some people develop symptoms of HSV a few days after coming into contact with the virus. Small, painful blisters or sores usually develop, which may cause itching or tingling, or make it painful to urinate.

Gonorrhoea

Gonorrhoea is a bacterial STI easily passed on during sex. About half of women and one in 10 men don’t experience any symptoms, and are unaware that they’re infected. In women, gonorrhoea can cause pain or a burning sensation when urinating, a vaginal discharge (often watery, yellow or green), pain in the lower abdomen during or after sex, and bleeding during or after sex or between periods. It can sometimes cause heavy periods.

Chlamydia

Chlamydia is passed on during sex. Most people don’t experience any symptoms, so they are unaware they’re infected. In women, chlamydia can cause pain or a burning sensation when urinating, vaginal discharge, pain in the lower abdomen during or after sex, and bleeding during or after sex or between periods. It can also cause heavy periods.

These are just a few of the STIs that exist. The World Health Organisation (WHO) estimates that more than one million people get an STI every day. The danger is that most people with sexually transmitted infections do not have any symptoms, and are therefore often unaware of their ability to pass infections on to their sexual partners.

Regular check-ups enable you to know what you have and how best to treat it. There are many risks posed by STIs. If left untreated, they can cause serious health problems including cervical cancer, liver disease, pelvic inflammatory disease (PID), infertility, and pregnancy problems.

The Well Project (thewellproject.org) says having some STIs (such as chancroid, herpes, syphilis, and trichomoniasis) can increase the risk of getting HIV if you are HIV-negative and are exposed to HIV. People living with HIV may also be at greater risk of getting or passing on other STIs.

But there is no need to fear. If you suspect that you might have contracted an STI, you must see your doctor and get it checked out. There are tests that can be performed to ascertain exactly what it is you might have. The tests include:

Blood tests, which can confirm a diagnosis of HIV, or the later stages of syphilis.

Urine samples: some STIs can be confirmed with a urine sample.

Fluid samples: if you have active genital sores, testing of fluid and samples from the sores may be done to diagnose the type of infection. Laboratory tests of material from a genital sore or discharge are used to diagnose some STIs.

Screening: testing for a disease in someone who doesn’t have symptoms is called screening. Most of the time, STI screening is not a routine part of health care; but there are exceptions:

It is advisable for women who are sexually active to test regularly. Once you are sexually active, you must go for PAP smear screening. The PAP smear screens for cervical abnormalities, including inflammation, pre-cancerous changes and cancer, which is often caused by certain strains of human papillomavirus (HPV).

All sexually active women should be tested for chlamydia infection. The chlamydia test uses a sample of urine or vaginal fluid you can collect yourself. Some experts recommend repeating the chlamydia test three months after you’ve had a positive test and been treated; the second test is needed to confirm that the infection is cured, as re-infection by an untreated or undertreated partner is common. A bout of chlamydia doesn’t protect you from future exposure; you can catch the infection again and again, so get retested if you have a new partner.

Screening for gonorrhoea is also recommended for sexually active women. If you happen to find yourself in a new relationship, it is of paramount importance that you both test for STIs.

Going to the clinic can be daunting. Remember that your health comes first! Keep that in mind when you go to seek assistance at any clinic.

Dr Sindisiwe van Zyl is a GP with a special interest in HIV. She is passionate about sharing health-related information, and has used social media extensively for this purpose. Dr Sindi – as she is affectionately known – is in private practice in Johannesburg. Twitter: @sindivanzyl

still speak to the massive challenge of ending period poverty, bringing dignity to more schoolgirls who are on their cycle, and shattering the stigma of and myths about menstruation.

For Sharon Gordon, CEO of Dignity Dreams, what struck her most in working with girls and schools in need has been a small reality that has little to do with startling numbers, but has been just as revealing.

Dignity Dreams is an NGO, started in 2013 with a mission to distribute free sanitary products to schoolgirls in need. Together with their various donors they distribute reusable cloth pads to schoolgirls who cannot afford them. In five years, the organisation has been able to distribute 67 000 packs of these reusable pads, to girls in South Africa and even to the Democratic Republic of Congo.

“I knew that the school principals would probably report back about improved attendance at schools after the distribution of the pads – almost because it’s become the norm to say this.

“We welcome the positive feedback; but research shows the reality is that the problem is less about menstruating girls who can’t afford sanitary towels staying away from school, and more about girls who are forced to use unreliable homemade products not being able to concentrate in class, or take part in sports and other school activities,” says Gordon.

However, it was one comment in a report-back that really stood out for her: schools were noting savings in their plumbing bills.

“Plumbers were being called out less to schools to unblock toilets, because girls were no longer throwing disposable pads and homemade sanitary towels into them,” says Gordon.

Items that used to be flushed down toilets included everything from disposable sanitary towels to pads made of newspaper, rags, and socks filled with sand. With the reusable pads, the girls were taking soiled pads home to be washed, dried and reused.

For Gordon, it bought home sharply the impact of positive intervention.

Dignity Dreams has also teamed up with a women’s upliftment collective employed to make the cloth pads for them. The packs contain six pads that can last four years, and they are distributed to Grade 8 pupils. The packs cost R200 each, and donors can also add panties to the packs that are distributed.

“We have focused on cloth pads because they have proved to be the product most acceptable to the girls, and the most sustainable. We also only have to visit a school once a year to distribute to every new Grade 8 class, rather than making monthly deliveries,” Gordon says.

Importantly, she adds, each delivery is an opportunity for outreach and education. The sessions are used to dispel myths and superstitions about periods – nonsense such as that washing your hair when you’re menstruating is unhealthy, or that periods are a sign of contamination.

Gordon is also pushing for men and boys to be informed about menstruation, so that period-shaming can stop; and so that society can let go of its discomfort about talking about periods, and be part of the solution to period poverty.

“We still hear things on distribution days, from teachers and principals,” she says, “saying things like ‘It’s wonderful that you have these pads, girls – now, hide them away.’”

“Periods are a bodily function, like blowing your nose, or having a wee – that’s the message we must get across.”

VAT on menstruation

The one-percentage-point VAT increase announced in February has been bad news for many, especially those campaigning for zero VAT on sanitary products.

In November last year, national treasury announced that tax exemption on sanitary towels would be put on hold – despite lobbying by activists and some members of Parliament for over a year. Instead, treasury urged individual departments to reallocate budgets in order to find funds to support subsidies or free pad-distribution initiatives.

The pressure from activists – and even from some in Parliament – was a direct response to growing evidence that girls who cannot afford sanitary pads and are then forced to use makeshift pads are compromised, in their learning and school and sports activities. They are not able to concentrate as well, and some even miss school days entirely as a result.

The number of girls in South Africa affected may not be the routinely quoted seven million, but could still be as high as around 2.6 million girls, according to fact-checking organisation Africa Check. They also found that absenteeism as a result of not having sanitary products was also not as high as the figures used for attention-grabbing headlines.

In the same fact-checking exercise Africa Check published in August 2016, they highlighted former President Jacob Zuma’s promise in 2011 that government would provide sanitary pads to indigent girls and women.

In February last year, through its social enrichment programme, the KwaZulu-Natal (KZN) Department of Education became the first province to roll out a free sanitary pad programme, to around 2 950 quintile 1 to 4 schools.

One year on, information and updates on the success and sustainability of this programme – launched with a R50 million budget – are still to be disclosed by the KZN Department of Education. Spotlight has tried several times to access updates on the programme, but has not received an informative response.

The Menstrual Cup

“I never thought it would happen to me,” Nonhlanhla Phume (25) told

menstrual cup

Spotlight. A few years ago, while menstruating, she noticed blood had leaked through and stained her pants while she was studying in a computer laboratory at Wits University.

“I was so embarrassed. I had to literally walk out with the chair I was sitting on, and take it to the bathroom and clean it. I was so self-conscious whenever I was menstruating after that,” she said.

But the worry around her menstrual period vanished after she started using a menstrual cup last year, given to her by the Maternal Adolescent and Child Health Research Unit as part of a DREAMS research project.

A menstrual cup is a small silicone cup-shaped device inserted into the vagina, which traps menstrual blood.

According to lead researcher Mags Beksinska the cup, which lasts five years, saves young women a significant amount of money. This is particularly relevant for poor school-going girls who have been reported to stay at home when menstruating, due to the unaffordability of sanitary products.

Beksinska said they are distributing 6 000 free cups to young women, primarily in all the institutions of higher education in three KwaZulu-Natal districts. Five hundred will be followed up for the study to find out what their sanitary challenges are, and what their experiences have been using the cup. School-going girls are not being targeted in this project because the provincial government provides sanitary assistance in schools; also, there were cultural concerns about virginity testing in relation to the use of the cup.

Phume, who is a project assistant for the menstrual cup study, said the product has not only saved her money, but also a lot of anxiety.

“Even though I had never even used a tampon before, I hardly notice the cup when it’s in. It never leaks, and I’m not stressed about that happening to me ever again.”